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Um, Maybe Imaging Went Up Because It Helps?

June 13, 2012
Written by: , Filed in: Diagnostic Imaging, Medical Ethics, Practice Management
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The authors of a new study, in The Journal of the American Medical Association, about imaging and radiation risks apparently never encountered the philosophical principle known as Occam’s Razor: seek the simplest explanation that fits the facts.

Researchers at the University of California, San Francisco, and Group Health Research Institute of Seattle were concerned about the increased radiation exposure that has accompanied the explosion in recent years of advanced imaging. They thought the imaging increase might stem from financial incentives built into the fee-for-service health care model.

Perhaps, they speculated, the story might be different at integrated health care delivery systems (also known as health maintenance organizations, or HMOs), which have financial disincentives for ordering expensive imaging procedures.

Instead, the study (in the June 13 issue of JAMA) found that imaging rates increased sharply from 1996 to 2010 in HMOs too.

Lead author Rebecca Smith-Bindman, MD, a professor of radiology and biomedical imaging at UCSF, said:

You would have imagined that the rate of increase would be lower.

Perhaps that should be “I would have imagined,” but never mind.

The researchers fret about the risks of increased radiation exposure and suggest that “evidence-based guidelines for using imaging should be developed that clearly balance benefits against financial costs and health risk.” That’s certainly a perfectly reasonable idea.

But a UCSF news release about the study seems obsessed with radiation risk even where there is none. The release says that in the HMOs studied, “The number of ultrasound examinations doubled, the number of CTs tripled, and the number of MRIs quadrupled. The analysis also showed enormous variation from system to system, with some types of imaging being done 5 to 10 times more often in one system compared to the others. This is significant, Smith-Bindman said, because on the national level, a lot of hope for countering the rise in imaging rates and radiation exposure has been pegged to removing financial incentives.”

How does a doubling in ultrasounds and a quadrupling in MRIs increase radiation exposure?

More fundamentally, the study seems to take for granted that the most likely motivation for doctors’ ordered more imaging is greed. It does grudgingly admit, “The increase in imaging use over this period was likely driven by many factors, including improvements in the technology that have led to expansion of clinical applications, patient- and physician-generated demand, defensive medical practices, and medical uncertainty.”

“Improvements in technology that have led to expansion of clinical applications.” One could say that.

Or one could say: “Imaging technology advanced at a dizzying pace, and doctors took advantage of it to better serve their patients. They felt the benefit to the patients outweighed the potential radiation risk.”

Maybe, in most cases, it’s just that simple.

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The National Science Foundation thinks a new tabletop X-ray laser is really cool; see our Facebook page for details. Personally, we’re not sure we’d want an X-ray laser on our table.

Related seminar: ALARA—CT (As Low As Reasonably Achievable)

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